Factors related to hemodialysis safety culture: integrative literature review

Integrative literature review, carried out through the steps: problem identification, bibliographic research, data evaluation, data analysis, and report. We adopted the guiding question: “What scientific evidence is there about the factors related to the safety culture in hemodialysis clinics, according to the nursing team?” The search was carried out in the LILACS, Medline / PUBMED, Scopus, CINAHL, Cochrane, and Web of Science (WOS) databases.

Results:

The sample of this review was composed of five studies. The factors found were: 8 predisposing, 13 disabling, 11 precipitating, and 18 reinforcing.

Conclusion:

The analysis of literary productions allowed an understanding of the main factors linked to nursing practices that influence the safety culture of patients on hemodialysis.

Descriptors:
Nephrology Nursing; Patient Safety; Hemodialysis Units, Hospital; Nursing Care; Precipitating Factors

Titles	Years Countries	Designs / samples	Interventions	Outcomes
Nurse Manager Safety Practices in Outpatient Hemodialysis Units⁽¹³13 Thomas-Hawkins C, Flynn L, Lindgren TG, Weaver S. Nurse Manager Safety Practices in Outpatient Hemodialysis Units. Nephrol Nurs J. 2015; 42(2):125-33. doi: 10.1891/1541-6577.29.1.1 https://doi.org/10.1891/1541-6577.29.1.1... ⁾	2015 US	Cross-sectional n = 422 nurses	-	The safety practices designed to reduce safety risk included: monitoring patient risk behaviors, enforce security policies and procedures, provide informal and formal education, manage patient flow, and involve patients in their care. Some practices relevant to the nursing team were: monitoring and observing staff; conduct formal audits; resolve security flaws in personnel care practices; and advise, train and take disciplinary action when necessary.
RN Staffing and Workload, Dialysis Work Environment, Processes of Nursing Care and Patient Safety Culture in Outpatient Hemodialysis Facilities⁽¹⁴14 Thomas-Hawkins C, Flynn L. RN staffing and workload, dialysis work environment, processes of nursing care, and patient safety culture in outpatient hemodialysis facilities [Abstract], Nephrology Nurs J [Internet]. 2013[cited 2018 Jul 10];40(2):170. Available from: https://www.annanurse.org/download/forms/meetings/symposium/abstracts13/thomas1.pdf https://www.annanurse.org/download/forms... ⁾	2013 US	Cross-sectional n = 422 nurses	-	Nurses reported at least monthly the occurrences of hypotension, patients' falls in the unit, and hospitalizations. The study observed significant associations between nurses' reports about patient transition and the increased probability of occurrences of ignored and shortened dialysis treatments; infiltration, infection, thrombosis and vascular access hemorrhage; family/patient complaints; medication error and use of the emergency room. There was also a significant association between the negative safety scores attributed by nurses and the greater probability of the occurrence of adverse events, such as inadequate staff levels, lack of procedural guidance, training, patient education, or application of policies.
The work environment of hemodialysis nurses and their impact on patients' outcomes⁽¹⁵15 Prezerakos P, Galanis P, Moisoglou I. The work environment of haemodialysis nurses and its impact on patients’ outcomes. Int J Nurs Pract. 2015; 21:132-40. doi: 10.1111/ijn.12223 https://doi.org/10.1111/ijn.12223... ⁾	2015 Greece	Cross-sectional n = 133 nurses	-	The disconnection of the venous needle from the fistula or graft was statistically significant when correlated with the work environment. Nurses who declared falls as frequent / very frequent scored low scores for the work environment (Mean = 2.1; SD = 2.2). Medication errors were reported as frequent (8.3%) to rare (64.7%). Catheter-associated infection and hypoglycemia were reported as frequent / very frequent adverse events - 39.8% and 26.4%, respectively.
Patient safety culture in nephrology nurse practice settings: Initial findings. Nephrology⁽¹⁶16 Ulrich B, Kear T. Patient safety culture in nephrology nurse practice settings: initial findings. Nephrology Nurs J [Internet]; 2014 [cited 2018 Jul 10];41(5):459-75. Available from: https://www.annanurse.org/download/reference/journal/patientSafety2.pdf https://www.annanurse.org/download/refer... ⁾	2014 US	Cross-sectional n = 979 Nurses	-	The study noted the most common safety-related concern in the underreporting of events and near misses, including lack of time, heavy documentation systems, absence of managerial support or monitoring of reported events, and actual or perceived punishment for the employee reporting an event. Focus on productivity was mentioned, weakening the focus on the patient. Nurses reported having many responsibilities and little time available to care for and verify the technicians' work. Events such as incorrect weights and lack of communication were also mentioned. The risk of infection was largely attributed to the lack of knowledge, time, and attention to protocols.
Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units⁽¹⁷17 Thomas-Hawkins C, Flynn L, Clarke SP. Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units. Nephrology Nursing Journal. 2008; 35(2): 123-131. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845981/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2008 US	Cross-sectional n = 422 nurses	-	the study has shown significant relationships between the occurrence of adverse events, such as volume overload; pneumonia hospitalizations, infection, infiltration, thrombosis, and bleeding in vascular access; fall with and without injury; medication errors; hypotension, shortened and ignored dialysis treatments; and patient complaints. The patient-nurse ratio of 12 or more was significantly associated with a higher probability of shortened dialysis times, just as patient complaints were ignored compared to the proportion of 4.61 or fewer patients per nurse.

	f(%)
Predisposing factors
Fall risk reduction	100
The decrease in patients hospitalization rate	40
The nursing team focus on patients and not on machines	40
Do not eat during treatment	20
Do not allow covering the patients' faces and access devices during treatment	20
Event and near miss notification	20
Volume overload reduction	20
Use of personal protective equipment in patients with hepatitis B	20
Disabling factors
Vascular access infection	100
Drug Errors	80
Hypotension	60
Vascular access thrombosis	40
Shortened dialysis times	40
Unexpected bleeding from vascular access	40
Vascular access infiltration	40
Failure to adhere to security procedures	40
Non-compliance in the waste disposal	20
Hypoglycemia	20
Failure of patients to clean their access sites before HD starts	20
Errors concerning dilution of the dialysis solution	20
Needle disconnection	20
Precipitating factors
Provision of knowledge, skills, and guidance needed by the nursing team	40
Effective communication during patient transfers and transitions in dialysis centers	40
Time availability for the nursing staff	20
Communication between nurses	20
Participation of nurses in hospital management matters	20
Provision of management support or monitoring of a reported event	20
No real or perceived punishment for an employee reporting an event	20
Analyze patient complaints	20
Evaluation of vascular access before the puncture	20
Sensitivity to patient complexity and complications	20
Absence of heavy documentation systems	20
Reinforcing factors
Adequate staffing	80
Provision of security policies, procedures, and guidelines	60
Strong leadership practice of the nursing team	40
Providing patient education	40
Hand washing	20
Wearing gloves	20
Training of new employees	20
Safety assessments during the patient transition	20
Productive communication relationship between doctor and nurse	20
Implementation of measures to adjust the prescription for patient hospitalization	20
Proper patient flow management	20
Monitoring and observation of nursing care	20
Active devices to monitor patient safety risks	20
Involving patients in their care	20
Proper water treatment	20
Monitoring of patient risk behaviors	20
Monitoring and effective management of patients' demands to start and finish their HD treatments	20
Proper teamwork	20

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[1] Corresponding author: Letícia Lima Aguiar. E-mail: leticiaaguiar1991@hotmail.com